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Older adults Flashcards
Lentigines
liver spots
appears as a wartlike growth that looks pasted on; found mostly on the back; color can range from tan to brown to black. Memory tip: The letter b in seborrheic is a reminder for benign.
seborrheic keratosis
a grayish-to-white ring in the margin of the cornea or on the periphery of the iris (cholesterol deposits).
arcus senilis
The most common cause of blindness in the United States is
macular degeneration
S4 is considered
normal in older adults
— and —- decreases with age but residual volume increases
FEV1 and FEV2
New onset or sudden increase in number of floaters or specks on the visual field, flashes of light, and the sensation that a curtain is covering part of the visual field. Considered a medical emergency that can lead to blindness if not treated. Risk factors are extreme nearsightedness, history of cataract surgery, and family or personal history of retinal detachment. Treated with laser surgery or cryopexy (freezing).
Retinal detachment
colorectal cancer screening begins at what age
45 - 75
If the chemistry profile shows marked elevations in the serum calcium and/or alkaline phosphatase, it is suggestive of
cancerous metastasis of the bone
most common cause of dementia in the US is
alzheimers
second cause of dementia in the US is
vascular dementia
Any dementia primarily caused by cerebrovascular disease or cerebral blood flow (e.g., multi-infarct/ischemic damage due to atherosclerotic plaques, bleeding, and/or blood clots)
vascular demenentia
Aggregated alpha-synuclein protein is a key component of Lewy bodies and Lewy neurites
Core clinical features include cognitive fluctuations, visual hallucinations, REM sleep behavior disorder, and parkinsonism (muscle rigidity, tremors). Executive function is impaired with fluctuations in alertness and cognition; sensitive to adverse effects of neuroleptics.
Dementia of Lewy bodies
Inability to recognize familiar people or objec
agnosiaa
apraxia
difficulty perfomring learned motor tasks
cardinal features of parkinsons is
tremor, bradykinesia, rigidity
Starting at dusk/sundown, the patient becomes very agitated, confused, and combative; symptoms resolve in the morning; seen more with dementia; recurs commonly.
sundowning phenomenon
mild to moderate dementia (MMSE 10 - 26) start what medication
cholinestrase inhibitor such as donepezil (aricept), exelon
moderate to severe dementia MMSE <18 add
namenda
first line treatment for essential tremor is
beta blocker propranolol
essential tremor
acton tremor
Selegiline (Eldepryl) is an MAO type B inhibitor. Avoid
Avoid tyramine-containing foods and caffeine due to risk of hypertensive crisis or serotonin syndrome. Drugs that alter serotonin are SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), TCAs, and MAOIs. Discontinue treatment if any symptoms arise.
Idiopathic Parkinson’s disease is associated with
low serum vitamin B12 levels due to levodopa. Check vitamin B12 level.
Wernicke–Korsakoff syndrome is caused by
vitamin B1 (thiamine) deficiency.
First-line treatment for Parkinson’s disease is
levodopa (Sinemet) immediate release.
Problems recalling words or names
anomia
Inability to recognize familiar objects placed in the palm (place a coin on palm and ask patient to identify object with eyes closed)
Astereognosis:
Which of the following is a category in the Katz Index of Independence in Activities of Daily Living?
A.Housecleaning
B.Dressing
C.Preparing meals
D.Exercising
Answer: B. Dressing
The Katz Index of Independence in Activities of Daily Living contains six items to assess a patient’s independence: bathing, dressing, toileting, transferring, continence, and feeding. The highest possible score is 6 points (independent), and the lowest is 0 points (very dependent).
duloextine can be helpful in what type of incontinence
Stress
The clinician asks a patient with Alzheimer’s disease to demonstrate how they use a comb. The clinician is assessing for which sign or symptom of the disease?
A.Apraxia
B.Aphasia
C.Amnesia
D.Agnosia
apraxia or dyspraxia, involves difficulty performing learned motor tasks, which can occur later in the disease progression of Alzheimer’s. The patient has the desire and physical ability to perform the tasks but has lost the ability to execute or carry out the skilled movement and gesture. Apraxia can be assessed by asking the patient to perform ideomotor tasks, such as using a comb. Progression of apraxia can cause difficulty with multistep motor activities, then with dressing, using utensils, and other self-care tasks. Aphasia involves language difficulty—the loss of spoken language or speech comprehension. Agnosia involves the inability to recognize and identify objects or persons. Amnesia refers to the loss of memory.
Which of the following findings is a concern, rather than an expected finding, in older adults?
A.Diminished appetite
B.Decreased visual acuity
C.Pill-rolling of the fingers
D.Difficulty staying asleep through the night
Answer: C. Pill-rolling of the fingers
The cardinal features of Parkinson’s disease are tremor, typically described as pill-rolling, bradykinesia, and rigidity. This is not a common finding seen with aging adults and may require further diagnostic workup. Cerebral neurons decrease with aging, and older adults experience decreased sensory functions of smell, taste, and vision. Nerve impulse conduction decreases, causing delayed responses to stimuli, unsteady gait, sleep disturbances, decreased level of cognition, diminished appetite, and decreased range of motion.
A patient’s family member reports that recently the patient has become acutely agitated and confused in the evening hours. The patient’s family member is concerned for the patient’s safety and asks for treatment recommendations. Which of the following interventions would be helpful for this condition?
A.Moving the furniture to avoid falls and safety hazards
B.Using a mechanism of distraction (e.g., playing music) when the patient is agitated
C.Administering an over-the-counter antihistamine to facilitate sleep
D.Using a dark room for sleeping to allow the patient proper sleep hygiene
Answer: B. Using a mechanism of distraction (e.g., playing music) when the patient is agitated
The patient’s symptoms suggest the sundowning phenomenon, characterized by behavioral deterioration in the evening hours. Distraction can be helpful during an episode of agitation. The patient should be encouraged to watch television, take a walk, play music, or engage in another familiar hobby. It is important to maintain sleep hygiene; however, an appropriately lit room with a radio, television, or clock can help re-orient the patient. A dark room can be a safety hazard because it impairs visual acuity. It is essential to maintain routine, and familiar surroundings are important, so furniture should not be moved. Drugs that can affect cognition (e.g., sedatives, antihistamines, hypnotics, narcotics) should be avoided because they can worsen cognitive impairment.
Screening for lung cancer is recommended for which of the following patients?
A.45-year-old with a 10 pack-year smoking history
B.55-year-old with a 20 pack-year smoking history who currently smokes
C.60-year-old with a 5 pack-year smoking history who currently smokes
D.65-year-old with a 15 pack-year smoking history who quit 20 years ago
Answer: B. 55-year-old with a 20 pack-year smoking history who currently smokes
The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose CT in adults age 50 to 80 years who have a 20 pack-year smoking history and currently smoke or quit within the past 15 years.
A patient presents with a sudden onset of new flashes of light, floaters, and black dots in their vision. The patient reports a disruption in vision, “like a curtain is being pulled down.” These symptoms suggest which medical emergency?
A.Retinal detachment
B.Amaurosis fugax
C.Homonymous hemianopia
D.Acute angle-closure glaucoma
Answer: A. Retinal detachment
Retinal detachment can cause light flashes, floaters, visual disruption (e.g., a dark shadow or “curtain”), and loss of peripheral and/or central vision. A patient with acute angle-closure glaucoma often presents with decreased vision, halos around lights, headache, severe eye pain, and nausea and vomiting. Homonymous hemianopia (often caused by cerebral infarction and intracranial hemorrhage) describes a visual field impairment involving the two right or the two left halves of the visual fields of both eyes. Amaurosis fugax refers to transient vision loss in one or both eyes. Transient vision loss may be seen in patients with giant cell arteritis.
Which of the following is a category in the Katz Index of Independence in Activities of Daily Living?
A.Housecleaning
B.Dressing
C.Preparing meals
D.Exercising
Answer: B. Dressing
The Katz Index of Independence in Activities of Daily Living contains six items to assess a patient’s independence: bathing, dressing, toileting, transferring, continence, and feeding. The highest possible score is 6 points (independent), and the lowest is 0 points (very dependent).
An older adult patient with a history of chronic urinary incontinence at baseline presents with a new onset of delirium and falls. Which of the following is an appropriate next step for this patient?
A.Serum creatinine
B.Urinalysis
C.Urine culture
D.Workup for onset of new delirium
Answer: D. Workup for onset of new delirium
It is not recommended to perform urine testing based on nonspecific symptoms (such as mental status changes and functional decline) in the absence of findings concerning for systemic infection. In the older adult population, urine testing is indicated in the presence of classic signs and symptoms of urinary tract infection (e.g., acute dysuria, new or worsening urgency or frequency, new incontinence, gross hematuria, suprapubic or costovertebral angle tenderness) or physiologic signs of serious acute illness (e.g., fever, other major vital sign abnormalities, changes in level of consciousness).
The clinician asks a patient with Alzheimer’s disease to demonstrate how they use a comb. The clinician is assessing for which sign or symptom of the disease?
A.Apraxia
B.Aphasia
C.Amnesia
D.Agnosia
Answer: A. Apraxia
Apraxia, or dyspraxia, involves difficulty performing learned motor tasks, which can occur later in the disease progression of Alzheimer’s. The patient has the desire and physical ability to perform the tasks but has lost the ability to execute or carry out the skilled movement and gesture. Apraxia can be assessed by asking the patient to perform ideomotor tasks, such as using a comb. Progression of apraxia can cause difficulty with multistep motor activities, then with dressing, using utensils, and other self-care tasks. Aphasia involves language difficulty—the loss of spoken language or speech comprehension. Agnosia involves the inability to recognize and identify objects or persons. Amnesia refers to the loss of memory.
A patient’s family member reports that recently the patient has become acutely agitated and confused in the evening hours. The patient’s family member is concerned for the patient’s safety and asks for treatment recommendations. Which of the following interventions would be helpful for this condition?
A.Moving the furniture to avoid falls and safety hazards
B.Using a mechanism of distraction (e.g., playing music) when the patient is agitated
C.Administering an over-the-counter antihistamine to facilitate sleep
D.Using a dark room for sleeping to allow the patient proper sleep hygiene
Answer: B. Using a mechanism of distraction (e.g., playing music) when the patient is agitated
The patient’s symptoms suggest the sundowning phenomenon, characterized by behavioral deterioration in the evening hours. Distraction can be helpful during an episode of agitation. The patient should be encouraged to watch television, take a walk, play music, or engage in another familiar hobby. It is important to maintain sleep hygiene; however, an appropriately lit room with a radio, television, or clock can help re-orient the patient. A dark room can be a safety hazard because it impairs visual acuity. It is essential to maintain routine, and familiar surroundings are important, so furniture should not be moved. Drugs that can affect cognition (e.g., sedatives, antihistamines, hypnotics, narcotics) should be avoided because they can worsen cognitive impairment.
A 60-year-old male patient had a colonoscopy this year, which was normal. The patient has no personal or family history of colon cancer. He asks when he needs to follow up with additional screening. The clinician recommends:
A.High-sensitive guaiac-based fecal occult blood test annually
B.Flexible sigmoidoscopy every 2 years
C.CT colonography every 3 years
D.Colonoscopy screening every 5 years
Answer: A. High-sensitive guaiac-based fecal occult blood test annually
According to the U.S. Preventive Services Task Force, it is recommended that adults age 45 to 75 years be screened for colorectal cancer. The recommended intervals for colorectal cancer screening tests for asymptomatic adults who are at average risk of colorectal cancer (i.e., no prior diagnosis of colorectal cancer, adenomatous polyps, or inflammatory bowel disease; no personal diagnosis or family history of known genetic disorders that put them at risk of colorectal cancer) are high-sensitivity guaiac-based fecal occult blood test or fecal immunochemistry testing (FIT) every year, stool DNA-FIT every 1 to 3 years, CT colonography every 5 years, flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy every 10 years + FIT every year, and/or colonoscopy screening every 10 years.
A female patient is in the hospital recovering from a motor vehicle collision. The patient sustained a femur fracture and is experiencing urinary incontinence due to impaired mobility that delays access to the bathroom. Which of the following treatment options would be appropriate for this patient?
A.Pelvic floor muscle (Kegel) exercises
B.Bedside commode and physical therapy
C.Duloxetine (Cymbalta), a serotonin-norepinephrine reuptake inhibitor
D.Bladder training
Answer: B. Bedside commode and physical therapy
This patient’s clinical manifestations suggest functional incontinence, which involves intact urinary storage and emptying functions; the patient has physical problems reaching the bathroom in a timely manner. Treatment options include use of a bedside commode and raised toilet seat with handles and physical therapy for strengthening and gait. Pelvic floor muscle (Kegel) exercises are especially useful for patients experiencing stress urinary incontinence. Bladder training is most effective for female patients with urgency incontinence. Duloxetine (Cymbalta), a serotonin-norepinephrine reuptake inhibitor, may be effective for stress urinary incontinence in some patients.
A patient presents with complaints of a bilateral action tremor in the arms and hands. The patient reports that the tremor is activated by voluntary movement, especially drinking from a glass. The tremor is absent when the affected body part is fully relaxed and supported. These symptoms suggest which of the following disease conditions?
A.Parkinson’s disease
B.Tardive dyskinesia
C.Acute akinesia
D.Essential tremor
Answer: D. Essential tremor
An essential tremor is an action tremor that often affects the hands and arms bilaterally. It can also be seen in the head, voice, and face or trunk (rare). Common daily activities are often affected, such as writing, drinking from a glass, and using utensils. Classically, tremor due to Parkinson’s disease is a rest tremor that occurs unilaterally, distinguishing it from an essential tremor. Tardive dyskinesia is a medication-induced hyperkinetic movement disorder that causes oral, facial, and lingual dyskinesia. A sudden exacerbation of Parkinson’s disease can cause acute akinesia, which causes an akinetic state (without motion) that can last for several days.
Which of the following cancers has the highest rate of mortality?
A.Lung and bronchus
B.Colorectal
C.Pancreatic
D.Breast
Answer: A. Lung and bronchus
Lung and bronchus cancer accounts for the most deaths, with 130,180 people annually expected to die from this type of cancer. Colorectal cancer is the second most common cause of cancer death, followed by pancreatic cancer, which is the third deadliest cancer. Breast cancer mortality has decreased due to increased screening, earlier detection, awareness, and improved treatment.
Which of the following medications for the treatment of constipation is considered an osmotic agent?
A.Psyllium
B.Docusate
C.Polyethylene glycol
D.Bisacodyl
Answer: C. Polyethylene glycol
Osmotic agents include polyethylene glycol, lactulose, sorbitol, glycerin, magnesium sulfate, and magnesium citrate. Bulk-forming laxatives include psyllium, methylcellulose, polycarbophil, and wheat dextrin. Docusate is a surfactant (softener). Stimulant laxatives include bisacodyl and senna.
A patient presents with pill-rolling, generalized slow movement, and increased resistance to passive movement. The patient reports a tendency to fall and a feeling of imbalance. These symptoms are suggestive of which disease pathophysiology?
A.Deposits of beta amyloid beta peptides
B.Ischemic damage due to atherosclerotic plaques
C.Dopamine depletion from the basal ganglia
D.Chronic thiamine deficiency
Answer: C. Dopamine depletion from the basal ganglia
The patient is presenting with clinical features consistent with Parkinson’s disease: a rest tremor (“pill-rolling”), generalized slowness of movement (bradykinesia), rigidity, and postural instability causing a feeling of imbalance and an increased risk of falls. The pathophysiology of Parkinson’s disease involves the progressive degeneration of dopamine-producing neurons in the basal ganglia, including the substantia nigra in the midbrain. Dopamine depletion causes major disruptions in the connections to the thalamus and motor cortex, leading to the classic presentation of bradykinesia and rigidity. The pathophysiology of Alzheimer’s disease involves the overproduction and/or decreased clearance of amyloid beta peptides, a family of proteins. Vascular dementia is caused by cerebrovascular disease or impaired cerebral blood flow. Wernicke’s encephalopathy results from thiamine deficiency.
The acronym CRAB can be used to recall the characteristics of multiple myeloma. Which of the following correctly represents the mnemonic?
A.C: Calcium levels low
B.R: Renal insufficiency
C.A: Anorexia
D.B: Bradycardia
Answer: B. R: Renal insufficiency
The diagnosis of multiple myeloma requires clonal bone marrow plasma cells greater than 10% or biopsy-proven bony or soft-tissue plasmacytoma, plus the presence of related organ or tissue impairment suggested by elevated Calcium levels, Renal insufficiency, Anemia, and Bone lesions (CRAB).
Which of the following findings is a concern, rather than an expected finding, in older adults?
A.Diminished appetite
B.Decreased visual acuity
C.Pill-rolling of the fingers
D.Difficulty staying asleep through the night
Answer: C. Pill-rolling of the fingers
The cardinal features of Parkinson’s disease are tremor, typically described as pill-rolling, bradykinesia, and rigidity. This is not a common finding seen with aging adults and may require further diagnostic workup. Cerebral neurons decrease with aging, and older adults experience decreased sensory functions of smell, taste, and vision. Nerve impulse conduction decreases, causing delayed responses to stimuli, unsteady gait, sleep disturbances, decreased level of cognition, diminished appetite, and decreased range of motion.
A patient with Alzheimer’s disease scores a 15 on the Mini-Mental State Examination (MMSE). Which of the following is an appropriate treatment option for this patient?
A.Initiation of memantine (Namenda) alone
B.Combination therapy of donepezil/memantine (Namzaric)
C.Initiation of donepezil (Aricept) alone
D.Maximizing of quality of life and patient comfort
Answer: C. Initiation of donepezil (Aricept) alone- think A first
For patients with mild-to-moderate dementia (MMSE 10–26), it is recommended to begin a trial of a cholinesterase inhibitor (increases longevity of acetylcholine), such as donepezil (Aricept). For patients with moderate-to-severe dementia (MMSE ≤18), it is recommended to add memantine (Namenda) in combination with a cholinesterase inhibitor or use memantine (Namenda) alone in patients who do not tolerate or benefit from a cholinesterase inhibitor. For patients with severe dementia (MMSE <10), memantine (Namenda) can be continued, or all drug administration may be discontinued to maximize quality of life.
Which of the following is a cardinal clinical sign in a patient with Parkinson’s disease?
A.Pill-rolling tremors
B.Inability to recognize familiar people or objects
C.Wide-based gait
D.Increased facial movements due to tics
Answer: A. Pill-rolling tremors
Clinical signs of Parkinson’s disease include pill-rolling tremors, difficulty initiating voluntary movements, and shuffling gait with cogwheel rigidity. Facial movement decreases, resulting in generalized rigidity with masked facies. Inability to recognize familiar people or objects, or agnosia, is a sign of Alzheimer’s disease. Wide-based gait is a sign of cerebellar ataxia.
A patient presents with one discrete lesion on the side of the head. Assessment reveals an erythematous, scaly macule that is 1 cm in diameter. Which of the following is an appropriate choice of therapy?
A.5% topical fluorouracil cream
B.Photodynamic therapy
C.No treatment because the lesion is less than 2 cm
D.Liquid nitrogen cryotherapy
Answer: D. Liquid nitrogen cryotherapy
The patient is presenting with the classic clinical features consistent with actinic keratosis: an erythematous, scaly macule, papule, or plaque lesion that ranges from a few millimeters to 2 cm in diameter. The choice of therapy depends on number and distribution of lesions, patient preference, side effects, and treatment availability. Liquid nitrogen cryotherapy can be used as treatment for patients with one or a few discrete, isolated lesions. First-line therapy for patients with multiple thin lesions on the face or scalp includes 5% topical fluorouracil cream. While photodynamic therapy is an alternative option for the treatment of multiple lesions, it is not available in all office-based dermatology offices.
Which of the following age-related changes increases an older adult’s risk for aspiration?
A.Gum recession exposing the tooth cementum
B.Decreased lower esophageal sphincter tone
C.Decreased food clearance from the pharynx
D.Delayed gastric emptying
Answer: C. Decreased food clearance from the pharynx
In healthy older adults, the strength and coordination of the tongue is impaired, causing less effective mastication. In addition, the transfer of a food bolus to the pharynx is altered, which leads to increased aspiration risk in older adults. The gums recede, exposing the tooth cementum, which puts the older adult patient at risk for decay and root caries. Diminished esophageal contractions and decreased lower esophageal sphincter tone result in increased gastric acid exposure. Delayed gastric emptying may contribute to increased rates of gastritis.
Which of the following is a physiologic change that occurs in the aging body?
A.Increased intrinsic heart rate
B.Hypertrophied left ventricle
C.Decreased platelet responsiveness
D.Increased muscle mass
Answer: B. Hypertrophied left ventricle
Physiologic changes that occur with aging include an increased prevalence of hypertrophy of the left ventricle, with an average increase in wall thickness of about 10%. Increased platelet responsiveness (resulting in a procoagulant state) and decreased intrinsic heart rate and muscle mass are other physiologic changes that occur in the older adult.
A patient presents with decreased vision, halos around lights, a severe headache, and eye pain. Physical assessment reveals conjunctival redness and corneal edema. Emergent ophthalmologic examination is necessary. Based on this clinical presentation, which of the following tests is the gold standard for diagnosis?
A.Dilated fundus examination
B.Gonioscopy
C.Visual field testing
D.Slit-lamp examination
Answer: B. Gonioscopy
The patient is presenting with signs and symptoms of acute primary angle-closure glaucoma. The clinical presentation often includes decreased vision, halos around lights, headache, severe eye pain, nausea, and vomiting. Clinical signs that suggest a rapid increase in intraocular pressure include conjunctival redness, corneal edema or cloudiness, a shallow anterior chamber, and a mid-dilated pupil (4 to 6 mm) that reacts poorly to light. Diagnosis begins with emergent examination of both eyes by an ophthalmologist, including the following tests: gonioscopy, visual acuity, evaluation of the pupils, measurement of intraocular pressure, slit-lamp examination of the anterior segments, visual field testing, and undilated fundus examination. Gonioscopy is the gold standard in the diagnosis of angle-closure glaucoma.
Which of the following physiological changes is present in the lungs of older adults?
A.Increased FEV1
B.Decreased residual volume (RV)
C.Increased lung compliance
D.Earlier airway collapse with shallow breathing
Answer: D. Earlier airway collapse with shallow breathing
In older adults, airways tend to collapse earlier with shallow breathing than in younger patients, which increases the risk of pneumonia. Lung compliance decreases with older age; therefore, FEV1 also decreases and residual volume increases.
An older patient has been taking digoxin (Lanoxin), metformin (Glucophage), atenolol (Tenormin), and aspirin for several months. During an office visit, the patient reports dark areas in the central vision fields. The patient’s digoxin level is 1.3 ng/mL. Which of the following is the most likely cause?
A.Acute angle-closure glaucoma
B.Cataracts
C.Retinal detachment
D.Age-related macular degeneration
Answer: D. Age-related macular degeneration
The patient is experiencing symptoms of macular degeneration (changes in central vision), which can be attributed to atenolol (Tenormin) use. The patient’s digoxin level is within normal range (0.7 to 1.5 ng/mL). Additionally, the patient’s vision changes are not typical of digoxin toxicity, which includes yellowish-green halos. Metformin (Glucophage) and aspirin do not cause macular degeneration.
normal digoxin level is
0.7-1.5
